The context

Demographic changes

The reduction in the fertility rate throughout South and South-West Asia has led to a ‘demographic dividend’ whereby the number of young people entering adulthood who were born during a time of higher fertility outnumbers the number of children being born, increasing the proportion of the population in the most productive (and mobile) ages of youth and young adults. Table 1 shows that the young adult population (ages 20–34) is growing more rapidly than the total population. It offers the opportunity for a demographic dividend because of the increasing proportion of the total population in the most productive age groups, but it also results in greater overall mobility because these ages are also the years of greatest personal mobility.

Rural-urban migration

There has been a marked redistribution of population in the subregion from rural to urban areas as both a cause and consequence of rapid social and economic change. This is evident in table 2, which shows that growth in the urban population is expected to be nine times that of the rural population between 2010 and 2030.

International migration and globalization

The globalization and internationalization of labour markets has led to an unprecedented number of international migrants from South and South-West Asia. While people from the region have been involved in an array of types of international mobility, such as skilled migration to Organisation for Economic Co-operation and Development (OECD) countries, marriage migration and student migration, the increasing flows of labour migrations are of particular significance. Not only are the numbers large and increasing, but it is the form that this mobility takes which is significant from a health perspective. This is because the migrant is usually an individual migrant worker that leaves his/her family behind for a period of two years and often lives under marginal conditions in the host country. Moreover, much of the movement takes place through informal and irregular channels. Migrants with an irregular status3 are estimated to comprise 15 per cent of the migrant population, and can be very vulnerable to negative impacts to their well-being and health, in particular. In cases of countries where demand for workers is high and no legal migrations systems are in place, migrants experience high levels of risks and exploitation. Smuggling, trafficking, bonded labour and lack of respect for human and worker rights are the fate of millions of migrants, most of them from poorer countries (GFMD 2011). Having an irregular migration status amplifies the potential for abuse and exploitation because these types of migrants do not have access to judicial channels of possible relief and redress in fear of imprisonment or deportation. In addition, lack of coverage for health services can lead to excessive costs for migrants many of whom have to cover their health costs out of their own pocket. This deters many of them from accessing services, which exacerbates health conditions that could have been prevented, often at reduced costs, if services had been available.

Patterns of disease

The nature of the burden of disease in terms of daily disability-adjusted life years (DALYs) has been shifting rapidly, with the proportion of communicable diseases, maternal and child health and nutrition problems decreasing and non-communicable diseases (NCDs) increasing. Figure 1 shows that in South Asia, NCDs and injuries account for 55 per cent of the disease burden. Nevertheless, it must be noted that communicable diseases still account for 46 per cent of the burden, which is higher than the global average. Hence, South Asia has a distinct health profile in that both communicable and non-communicable diseases each make up a sizeable portion of the sub-region’s disease burden.

Poverty

Disease patterns are influenced by, and influence, the broader human development profile of the region. Figure 1 shows that among the low- and middle-income sub-regions, South Asia has relatively low economic indicators and that its population has the lowest life expectancy with the exception of Sub-Saharan Africa. Moreover, the sub-region’s expenditure on health as a percentage of GDP and the amount spent per capita is the lowest among the world’s sub-regions. Hence, the availability of health services and access to health services in the total population, let alone among migrants, is low.

Humanitarian crises

The high incidence of crises related to natural disasters and political conflict prevalent among many counties in South and South-West Asia influences the migration and health relationship. A survey published online by The Disaster Center shows that of the 100 natural disasters that killed the most people during the twentieth century, approximately one-third occurred in South and South-West Asia, most notably in Bangladesh and India. Natural disasters not only cause massive loss of life but they often displace huge numbers of people on both a permanent and temporary basis and this displacement can expose those moving to a number of health risks (Disaster Center no date). Particularly in South Asia, disasters often destroy houses and livelihoods, forcing the survivors into overcrowded and often unhealthy camps where there is a high risk of the spread of infectious disease.
The onset of climate change is likely to increase the incidence of some natural disasters and some areas in South and South-West Asia are among the most vulnerable to this global phenomenon. Hugo and others (2009) lists the following as major hot spots:

  • Increased flooding in major river valleys such as Pakistan.
  • Reduced rainfall across major parts of India.
  • Exposure of coastal areas, especially in Bangladesh, to a rise in the sea level and increased storm surge damage.

These changes, which have already been observed in the sub-region, especially in the hot spot areas, will impact migration both as an adaptation to climate change but also due to some displacement of populations. In Bangladesh, for example, table 4 summarizes current and projected environmental hazards and shows the scale of the impact—previous and anticipated.

In addition, some of the countries of the sub-region have been flashpoints of conflicts, which have generated millions of refugees and internally displaced persons (IDPs) in recent decades. The displacement process and the subsequent concentration of refugees and IDPs in camps expose these migrants to significant health risks.

Of particular concern is the health of women and girls who are displaced by natural or man-made disasters. The limited data available on sex and gender differences with regard to vulnerability to and impact of disasters show that the health of women and girls is at disproportionate risk compared to men. This is due to (sexual) violence, lack of protection and access to reproductive health services, social and cultural beliefs, taboos and norms, particularly those that place women as a subordinate to men in terms of access to resources and decision-making power.

 

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3 Migrants in an irregular situation are people who, owing to illegal entry or the expiry of his or her visa, lack legal status in a transit or host country. The term applies to migrants who infringe a country’s admission rules and any other person not authorized to remain in the host country (IOM 2004).